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Aetna Medicare Enhanced (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Enhanced (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Enhanced (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Enhanced (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in WI Southeast. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Enhanced (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Aetna Medicare Enhanced (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Aetna Medicare Enhanced (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $30.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10100.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10100.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Aetna Medicare Enhanced (PPO) prescription drug plan features an annual drug deductible of $615. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic drugs when using a preferred pharmacy or preferred mail-order service. If you fill these generic prescriptions at a standard pharmacy or standard mail-order service, Tier 1 copays start at $2.00 and Tier 2 copays start at $12.00 for a one-month supply. For higher-tier medications, your costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance across all pharmacy and mail-order options. This structure helps you easily estimate your out-of-pocket expenses for both generic and brand-name prescriptions under this PPO plan.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust medical coverage with predictable costs, featuring no copay and no coinsurance for primary care visits and routine preventive services. Specialist visits, urgent care, and emergency room services are highly accessible with low copayments and no coinsurance. For inpatient hospital stays and outpatient procedures, members will generally pay set daily or per-service copays with no coinsurance, helping keep out-of-pocket costs manageable. This plan also provides valuable supplemental benefits, including routine dental cleanings, annual eye exams, and routine hearing tests with no copays or coinsurance. Coverage extends to home health services with no copay, while essential medical equipment and diagnostic services feature minimal coinsurance and no copayments. Additionally, prescription hearing aids and eyewear are partially covered up to annual allowance limits to help reduce your personal healthcare expenses.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Aetna Medicare Enhanced (PPO) with no coinsurance, though prior authorization is required. For acute care, you will pay a $310 daily copay for days 1 through 7 and no copay for days 8 and beyond, while psychiatric care requires a $265 daily copay for days 1 through 8 and no copay for days 9 through 90. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, including ambulatory surgical center and outpatient blood services which have no copays. Outpatient hospital and observation services have copays ranging from $0 to $310, while outpatient substance abuse sessions require a $40 copay, all with no coinsurance.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization with a copay of $75.00 or $145.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by the Aetna Medicare Enhanced (PPO), which requires a $280 copay and no coinsurance for ground ambulance services, and a 20% coinsurance with no copay for air ambulance services, subject to prior authorization. For transportation, some services are covered, but transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency room visits with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgent care with a $35 copay and no coinsurance. Worldwide emergency services are also covered up to a $250,000 maximum limit with no coinsurance, requiring a $130 copay for emergency or urgent care and a $280 copay for emergency transportation.
Primary Care See details
Aetna Medicare Enhanced (PPO) offers primary care physician visits with no copay and no coinsurance, and specialist visits with no copay to a $35 copay and no coinsurance. Most other covered services, like therapies and mental health, have copays between $35 and $40 with no coinsurance (telehealth has no copay to a $40 copay and 20% coinsurance), while podiatry is not covered and chiropractic care is only partially covered (routine and other chiropractic services are not covered).
Preventive Services See details
Preventive Services are partially covered by the Aetna Medicare Enhanced (PPO) plan, with most covered options like annual physicals and diabetes training requiring no copay and no coinsurance. Kidney disease education is covered with no copay and a 20% coinsurance, but several supplemental services like weight management, in-home safety assessments, and nutritional benefits are not covered.
Hearing Services See details
Aetna Medicare Enhanced (PPO) covers Medicare-covered hearing exams with a $35 copay and no coinsurance, while annual routine exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to a $500 annual limit per ear, but inner ear, outer ear, over-the-ear, and over-the-counter hearing aids are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no deductibles and no coinsurance, offering routine annual eye exams with no copay and Medicare-covered exams with a copay ranging from $0 to $35. Eyewear, including lenses, frames, and contact lenses, is also covered with no copay up to a $150 annual maximum, with a $50 annual maximum applying to eye exams.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (PPO), which features a $35 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for routine cleanings, exams, and x-rays. Comprehensive services have no copay and 20% to 50% coinsurance up to a $1,500 annual limit, though fluoride, implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive dental services are not covered.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Part B insulin is covered with a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other drugs require a coinsurance of 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Aetna Medicare Enhanced (PPO) plan with no copay and a 20% coinsurance, subject to prior authorization.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, medical supplies, and diabetic equipment, with prior authorization required. Under this plan, these benefits feature no copays, and coinsurance ranges from no coinsurance up to 20% depending on the service.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Aetna Medicare Enhanced (PPO), with prior authorization required for all services. Diagnostic lab services have no copay or coinsurance, diagnostic tests range from a $0 to $100 copay with no coinsurance, outpatient X-rays require a $20 copay plus coinsurance, and therapeutic radiological services have a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Aetna Medicare Enhanced (PPO) plan with no coinsurance. Patients are responsible for a $20 copay for cardiac and intensive cardiac rehabilitation, a $15 copay for pulmonary rehabilitation, and a $25 copay for supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD).
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered under the Aetna Medicare Enhanced (PPO) plan with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $211 daily copay for days 21 to 100. Prior authorization is required, a prior three-day inpatient hospital stay is not required for admission, and additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) partially covers other services, offering an annual wellness exam, screening mammography, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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